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Visiting department: gynecological treatment cost: about (5000-10000 yuan) in the top three hospitals in the city. Cure rate: treatment cycle: treatment method: drug treatmentGeneral treatment of vulvar melanoma
First, Western medicine treatment of vulvar melanoma
1. Management of pigmented lesions of vulva
It is not necessary to remove all pigmented lesions of vulva, especially benign nevus, but biopsy is necessary when malignant transformation or malignant tumor is suspected clinically. All congenital nevus, borderline nevus and atypical hyperplastic nevus should be removed. Excision should be considered for lesions with diameter > 5mm, irregular boundary, unclear and spotted pigmentation. In addition, pigmentation lesions increase, pigment deepens, irritation symptoms or ulcer bleeding should be removed. Atypical nevus with family history or melanoma history and/or other similar medical history should be followed up under the close supervision of skin cancer experts.
2. Surgical treatment
(1) Operation method:
The treatment of vulvar melanoma is a balance, which not only achieves local disease control but also reduces the cure rate, not the wider the operation scope, the better. The traditional standard method for treating vulvar melanoma is similar to the treatment of vulvar squamous cell carcinoma, that is, radical vulvar surgery plus bilateral inguinal lymph node and pelvic lymph node resection. As the treatment of vulvar squamous cell carcinoma tends to be individualized and the scope of operation is narrowed and the treatment of skin melanoma in other parts becomes more conservative, the concept of surgical treatment of vulvar melanoma has also changed. In 1987 Davidson and others reported 32 cases of vulvar melanoma and vaginal melanoma. No matter whether radical surgery or simple vulvar resection or simple local resection or whether it is assisted by radiotherapy, there is no difference in therapeutic effect. Radical operations included simple radical vulvectomy, radical vulvectomy plus inguinal lymphadenectomy or anterior pelvic visceration. Therefore, the authors recommend local resection, plus inguinal lymph node resection if there is clinical evidence of inguinal lymph node metastasis. Radical surgery should be considered for patients with massive vulvar lesions or extensive local recurrence. Subsequent clinical studies in several centers have not confirmed that extensive surgery is superior to local resection with 2cm margin. Verschraegen and colleagues in 2001 reviewed their treatment of 51 cases of pudendal melanoma from 1970 to 1997, and found that the surgical technique itself did not change the prognosis of the patients.
(2) Surgical margin:
Whether the surgical margin is complete or not has a significant relationship with the recurrence of the disease and the prognosis of patients. Rose et al. found that 6 cases were treated by conservative operation, and the incision margin<2cm，其中3例复发，而6例切缘>Only one patient with 2cm recurred. Trimble and his colleagues summarized the therapeutic effects of 80 patients with vulvar melanoma. Compared with incomplete radical surgery, radical surgery does not seem to improve the prognosis of patients. It is suggested that local radical resection with a margin of 1 ~ 2cm should be performed for thin lesions with invasion depth ≤ 1mm in Chung ⅱ, and the margin of thick lesions with a margin of 3cm should be required for Chung ⅲ and ⅳ. Simple resection and close follow-up should be performed for Chung ⅰ. In order to prevent recurrence, even lesions【小于】0.76 mm deep should have sufficient incision margin. Some authors suggest that a local resection with a 3cm surgical margin can achieve the therapeutic effect of all patients with vulvar melanoma. Zang Rongyu reported the treatment experience of 15 cases of vulvar melanoma in China. They suggested that in the early stage (AJCCI stage II), extensive resection of vulvar tumor alone should be feasible, and the cutting edge should be more than 3cm away from the tumor edge. In the late stage, comprehensive treatment should be emphasized, and extended operation could not improve the prognosis.
Based on the above research, it is considered by some scholars that it is a reasonable treatment strategy to remove the normal skin margin of 1cm for vulvar melanoma with thickness less than 1mm, and to remove the skin margin of 2cm for tumors with thickness of 1 ~ 4mm.
(3) Management of regional lymph nodes:
GOG analyzed 71 patients with vulvar melanoma, and found that FIGO stage, tumor size and location, capillary-lymphatic involvement and Breslow tumor invasion depth were significantly related to lymph node metastasis, which meant that the prognosis of patients was extremely poor. The depth of skin lesions found in large-scale skin melanoma studies<0.76mm者淋巴结转移危险性十分低，将不能从淋巴结切除术中获得益处，而病灶浸润深度>4.0 mm patients have a very high risk of lymph node metastasis and recurrence, and they also have little benefit from lymph node resection. Patients with primary lesion depth of 0.76 ~ 4.0 mm may benefit from selective lymphadenectomy. Not all patients with vulvar melanoma have selective lymphadenectomy. Chung thinks that Chung ⅱ (tumor thickness ≤ 1mm) does not need lymphadenectomy. Trimple et al. recommended prophylactic lymphadenectomy for patients with lesion thickness > 0.76 mm (Clark III), because patients with positive lymph nodes can survive for a long time. Prophylactic lymphadenectomy and radical vulvectomy for patients with lymph node micrometastasis can make patients survive for 10 yearsThe rate is 31%. A prospective study on lymph node resection and resection types of vulvar melanoma from Phillips et al. Compared with those without lymph node resection, positive lymph node resection or negative lymph node resection failed to show the advantages of lymph node resection. To sum up, for patients with vulvar melanoma with invasion depth> 0.76 mm (Clark ⅲ grade), ipsilateral lymph node resection should be considered for patients with lateral lesions, and bilateral lymph node resection for patients with central lesions. Removing clinically involved lymph nodes is always beneficial to patients with vulvar melanoma.
3. Chemotherapy and radiotherapy
In the past, melanoma was considered to be tolerant to chemotherapy and radiotherapy, but in recent years, data show that advanced patients are effective for chemotherapy and radiotherapy, and radiotherapy and chemotherapy alone can make individual patients survive for more than 10 years. Commonly used chemotherapy drugs are dacarbazine, lomustine, cisplatin (DDP), vinblastine sulfate, vincristine (VCR) and so on. The most effective chemotherapy drug for melanoma is dacarbazine (DTIC), and the response rate is 15% ~ 25%. Only 1% ~ 2% of patients treated with dacarbazine (DTIC) get long-term complete remission. DVP regimen (dacarbazine, vincristine, cisplatin), CPD regimen (lomustine, procarbazide, actinomycin D), BDPT regimen (carmustine, dacarbazine, cisplatin, tamoxifen) and VCD regimen are commonly used.
Carmustine (BCNU): 150mg/㎡ intravenous drip on the first day, once every 6 ~ 8 weeks.
Dacarbazine (DTIC): 200 ~ 220mg/㎡ intravenous drip for 1 ~ 3 days, once every 3 ~ 4 weeks.
Cisplatin (DDP): 25mg/㎡ intravenous drip once every 3 ~ 4 weeks for 1 ~ 3 days.
Tamoxifen: 10mg, twice a day, orally. 6 ~ 8 weeks is a course of treatment.
Cisplatin (DDP): 20mg/㎡ intravenous drip for 1 ~ 4 days.
Vinblastine sulfate (VLB): 1.5 mg/㎡ intravenous drip for 1 ~ 4 days.
Dacarbazine (DTIC): 200mg/㎡ intravenous drip for 1 ~ 4 days, or 800mg/㎡ intravenous drip for 1 day.
3 ~ 4 weeks is a course of treatment.
External irradiation can be used for local vulva and inguinal area, and vaginal afterloading can be used for tumor involving vagina or vaginal recurrence. Radiotherapy dose ranged from 4000cGY to 5000cGY, and local control was mainly improved for high-risk patients. Radiotherapy can also be used for distant brain, bone and visceral metastasis, which plays a role in relieving treatment. Radiotherapy can only relieve the symptoms of vulvar melanoma in advanced patients, whether it is used routinely or as a remission treatment, but it still cannot cure the disease.
(1) Interferon alpha:
ECOGG (Eastern CooperativeOncology Group) evaluated 280 melanoma patients with stage ⅱ B or stage ⅲ or regional lymph node metastasis. 137 patients served as controls, and 143 patients were treated with interferon. The use of interferon was 20MU/(㎡ d), intravenous administration 5 times a week for 4 weeks, and then changed to 10MU/(㎡ d), subcutaneous injection 3 times a week for 48 weeks. Results: Recurrence-free survival and overall survival were significantly prolonged in the treatment group, and the beneficiaries of interferon treatment were those patients with lymph node involvement. A further study of EC0G found that high-dose interferon can significantly prolong the tumor-free survival and overall survival of patients with high-risk melanoma after operation. This effect is unmatched by any other drugs, cytokines and other forms of vaccines.
Melanoma is the most immunogenic tumor, so melanoma has been regarded as the main model of tumor vaccine treatment research. IgM and IgG globulins in serum of melanoma patients can react differently to autologous and allogeneic melanoma, and about 1/3 patients are complicated with the phenomenon of lymph node concentration in tumor nodules. Freeze-dried BCG (BCG, tuberculin) can enhance the phagocytosis of reticuloendothelial system. Skin scratching method of freeze-dried BCG (BCG) can be used, 75 ~ 150mg each time, with an area of 7cm × 8cm. The therapeutic effect of 15 cases of genital tract melanoma was reported in China. It was found that all patients who survived for more than one year were treated with surgery, chemotherapy and freeze-dried BCG immunotherapy, and the effect was better. With the development of molecular biology technology, some genes compiling specific melanoma antigens have been cloned, and specific antigen polypeptide molecules have been identified. Based on the principle that specific antigens can stimulate the body to produce specific active immune response, new specific anti-melanoma vaccines have been developed. In 1998, Piura reported a 25-year-old patient suffering from Clark IV grade primary vulvar melanoma. After operation, he was treated with heterologous specific anti-melanoma vaccine, which achieved long-term remission and survived for more than 5 years, creating a precedent for active immunotherapy of vulvar melanoma.
(3) Adi interleukin (interleukin-2):
At present, there is no agreement on the therapeutic dose and medication time of interleukin alone. Although interleukin combined with chemotherapy and/or interferon can achieve high remission response rate, it can not achieve good long-term survival.
Treatment of vulvar melanoma based on syndrome differentiation
Second, traditional Chinese medicine remedies for vulvar melanoma
1. ready-for-use traditional Chinese medicine is taken orally
(1) Xihuang Pill can clear away heat and toxic materials, eliminate phlegm and dissipate stagnation, promoting blood circulation and relieving pain. It is mainly used for treating phlegm and blood stasis and severe pain. 3g per pill, 1 pill each time, twice a day.
(2) Xiaojinwan 6g, twice a day. It is suitable for phlegm and blood stasis.
(3) Dahuang Shuchong Pill is one pill each time, twice a day. It is suitable for qi stagnation and blood stasis type.
(4) Liuwei Dihuang Pills are 20 pills each time, twice a day. It is suitable for yin deficiency of liver and kidney.
(5) Fuzi Lizhong Pill is one pill each time, twice a day. It is suitable for spleen and kidney yang deficiency.
2. Diet aftercare after surgery
(1) Gas consumption hurts blood, so it is advisable to eat more products for invigorating qi and nourishing blood, such as jujube, longan, lentils, japonica rice, litchi, mushrooms, carrots, quail eggs, lotus root starch, beans, etc.
(2) When radiotherapy consumes yin-damaged liquid, it is advisable to eat more yin-nourishing liquid products, such as spinach, small vegetables, lotus root, plow, watermelon, banana, grape, sea cucumber, sugar cane, lily, etc.
(3) Chemotherapy is prone to loss of both qi and blood, so it is advisable to eat things that nourish qi and blood, such as fungus, mushrooms, walnut kernel, mulberry, coix rice porridge, red dates, longan, sea cucumber, etc.
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